Institute Of Medicine Report Research Articles

THE STATE OF GERIATRIC PSYCHIATRY TRAINING IN GENERAL PSYCHIATRY RESIDENCY: DATA FROM A NATIONAL SURVEY OF U.S. PROGRAM DIRECTORS

Introduction The 2012 Institute of Medicine (IOM) report identified a staggering increase in older adults with anticipated need for mental health and substance use treatment (1). By 2030, the United States population of elderly adults is anticipated to increase from 40.3 to 72.1 million, with 14-20% of this population estimated to have a mental health or substance use disorder ( 1 ). However, the IOM report cautions that the projected workforce remains inadequate to meet these pressing needs. Geriatric psychiatrists play a critical role providing subspecialty care to elderly patients with mental health, substance use, and neurocognitive disorders. Since 2010, the total number of geriatric psychiatry fellows has plummeted by 31% ( 4 , 5 , 6 ); this decrease in numbers ( 2 ) is a substantial concern. This study aims to investigate geriatric psychiatry training opportunities in general adult psychiatry residency programs and specific educational factors which may be associated with residents pursuing geriatric psychiatry subspecialty training. Methods The American Medical Association's Fellowship and Residency Electronic Interactive Database Access (FREIDA) was queried to compile a contact list of program directors from Accreditation Council on Graduate Medical Education (ACGME) accredited general adult psychiatry residency programs ( 3 ). The program directors were emailed an anonymous multiple choice survey using Qualtrics software to ascertain the nature of their program's geriatric psychiatry training experiences. The survey's domains of inquiry included the following: the quantity and quality of geriatric clinical and didactic experiences, the settings of training in geriatric psychiatry, the number of faculty with geriatric psychiatry specialization, and the number of graduates who pursued geriatric fellowships. Program directors were also asked about their familiarity with the American Association for Geriatric Psychiatry (AAGP) Scholars Program. Data analysis will be performed on survey responses. Results The authors will present survey data and compare results to previously published literature. Conclusions This work will contribute to the field by describing the current state of geriatric training in general psychiatry residency and examining whether these educational factors correlate to residents pursuing geriatric psychiatry fellowships. This research was funded by No funding sources supported this work.

Editorial introductions

Editorial introductions

Incorporating geriatric patient reported outcomes into novel screening tool of distress and supportive care concerns.

37 Background: The Institute of Medicine (IOM) 2013 Report recommends that supportive oncology care start at cancer diagnosis; the Commission on Cancer (CoC) Standard 3.2 requires distress screening and indicated action. The Supportive Oncology Collaborative, collaborative of 100+ clinicians funded by The Coleman Foundation, developed a patient-centric screening tool (CSOC-ST) adapted from ASCO Distress, NCCN Distress Problem List, IOM report and CoC standards, and other validated sub-tools (Weldon, ASCO-Q 2017). The Collaborative then revised the CSOC-ST tool to align with geriatric guidelines. Methods: Literature and guidelines review of geriatric screening, added items to CSOC-ST, and piloted at 4 sites. Descriptive statistics and Fisher’s exact test used. Results: 473 patients screened with added geriatric relevant items to CSOC-ST: self-care concerns (PROMIS Instrumental Support), living alone (ASCO Distress 2014), and memory / cognition (PROMIS item bank). Treatment/care concern items were revised to identify health care power of attorney and advance directive interest. Geriatric related items endorsed by patients, see Table. PHQ4, Anxiety and Depression, average score 2.4 (mild > 3). Higher scores on the PHQ-4 were significantly associated with each of the following: self-care concerns, memory/cognition concerns and specific treatment/care concerns (p < .0001). Conclusions: Pilot results and comparison to geriatric guidelines identified important items to support geriatric patient reported outcomes screening. After pilot, added 3 items for falls/frailty. Eight sites implementing this CSOC-ST.[Table: see text]

Incorporating geriatric patient-reported outcomes into novel screening tool of distress and supportive care concerns.

198 Background: The Institute of Medicine (IOM) 2013 Report recommends that supportive oncology care start at cancer diagnosis; the Commission on Cancer (CoC) Standard 3.2 requires distress screening and indicated action. The Supportive Oncology Collaborative, collaborative of 100+ clinicians funded by The Coleman Foundation, developed a patient-centric screening tool (CSOC-ST) adapted from ASCO Distress, NCCN Distress Problem List, IOM report and CoC standards, and other validated sub-tools (Weldon, ASCO-Q 2017). The Collaborative revised the CSOC-ST tool to align with ASCO geriatric guidelines. Methods: Literature and guidelines review of geriatric screening, added items to CSOC-ST, and piloted at 4 sites. Descriptive statistics and Fisher’s exact test used. Results: 473 patients screened with added geriatric relevant items to CSOC-ST: self-care concerns (PROMIS Instrumental Support), living alone (ASCO Distress 2014), and memory / cognition (PROMIS item bank). Treatment/care concern items were revised to identify health care power of attorney and advance directive interest. Geriatric related items endorsed by patients, see Table. PHQ4, Anxiety and Depression, average score 2.4 (mild > 3). Higher scores on the PHQ-4 were significantly associated with each of the following: self-care concerns, memory/cognition concerns and specific treatment/care concerns (p < .0001). Conclusions: Pilot results and comparison to ASCO geriatric guidelines identified important items to support geriatric patient reported outcomes screening. After pilot, added 3 items for falls/frailty. Eight sites implementing this CSOC-ST.[Table: see text]

Improving quality of cancer survivorship care: From framework to action.

49 Background: One decade after the Institute of Medicine report recommended the development of quality of cancer survivorship care measures, there remains little progress in achieving that goal. Our goal was to develop a framework for quality measurement and outline the next steps needed to drive research, policy and clinical care. Methods: We conducted a scoping review to identify quality domains and indicators for cancer survivorship care that included: (1) published cancer/cancer survivorship guidelines; (2) National Cancer Institute and Patient-Centered Outcomes Research Institute-funded cancer survivorship studies; (3) U.S. state Comprehensive Cancer Control Plans; (4) indicators developed by national quality organizations. We also reviewed published literature, specifically focusing on narrative and systematic reviews, commentaries/editorials and position papers addressing cancer survivorship care quality. We then conducted interviews with key experts in cancer survivorship and quality. Once the framework was developed, we convened a stakeholder meeting to outline actionable next steps. Results: Key domains focused on (1) cancer and its treatment, specifically prevention and surveillance of recurrences and second cancers as well as surveillance and management of physical and psychosocial effects and (2) primary health care needs such as management of multiple medical conditions and health promotion. Patient experience, communication, care coordination and health care delivery structure are critical domains in cancer survivorship care that must be measured. Lastly, domains included health care outcomes, such as utilization, costs, mortality and quality of life. Respective indicators and findings from stakeholder meeting will be presented at the Symposium. Conclusions: We developed a framework that will promote a systematic approach to (1) designing effective, evidence-based clinical care for cancer survivors in oncology and primary care settings, (2) expanding research initiatives to address identified gaps in quality measurement and (3) developing policy recommendations to encourage the implementation of standardized measures for quality improvement.

Medical Nutrition Therapy for Patients with Non–Dialysis-Dependent Chronic Kidney Disease: Barriers and Solutions

Medical Nutrition Therapy for Patients with Non–Dialysis-Dependent Chronic Kidney Disease: Barriers and Solutions

It Takes a Village… RN Diploma to BSN Program

Educational mobility is familiar to diploma and associate degree faculty and is emphasized in the Institute of Medicine Report, The Future of Nursing. Utilizing this premise, a team of nurse educators and administrators implemented the principles of organizational redesign, change process, and project planning to facilitate a transformation from a hospital-based diploma program to a university bachelor of science in nursing program. The process described truly exemplifies the fact that “it does take a village” to create success.

Indoor mould exposure, asthma and rhinitis: findings from systematic reviews and recent longitudinal studies.

Starting from the Institute of Medicine (IOM) and World Health Organization (WHO) reports, this review provides an overview of the literature published from 2006 to 2017 on the associations between indoor mould exposure and asthma and rhinitis separately in children and adults with a focus on longitudinal epidemiological studies.A systematic search of peer-reviewed literature was performed, including systematic reviews and meta-analyses, longitudinal, incident case-control and panel studies. 61 publications were identified reporting visible mould or mould odour or quantitative assessment of culturable fungi or mould species.In children, visible mould and mould odour were associated with the development and exacerbations of asthma, providing sufficient evidence of a causal relationship. Results from population-based studies in adults were too few and divergent to conclude at more than a limited level of evidence. Exposure to mould in a work building was associated with the incidence and exacerbations of occupational asthma, and we concluded at a sufficient evidence for an association. Systematic reviews, meta-analyses and longitudinal studies on the relationships between mould exposure and allergic rhinitis provide sufficient evidence of an association.This review extended the conclusions of the IOM and WHO reports, and highlighted the need for further longitudinal studies on asthma in adults, and on rhinitis.

Strategies used to facilitate the discussion of advance care planning with older adults in primary care settings: A literature review.

The purpose of this literature review was to evaluate strategies used in primary care settings to initiate advance care planning (ACP) conversations leading to the completion of an advance directive (AD). Approximately 50% of older adults have an AD; few talk to their primary care provider (PCP) about end-of-life wishes. The Institute of Medicine report and recent changes in Medicare reimbursement policies create opportunities for PCPs to address ACP in primary care settings. We used a systematic review approach. The search included seven Elton B. Stephens Company databases, limited to English language and peer-reviewed publications from 1991 to 2017 using 10 key words. Effective interventions were educational materials using various methods of delivery, computer-generated triggers for PCPs, inclusion of multidisciplinary professionals for content delivery, and patient preparation for PCP visit. The identified strategies provide a starting point for PCPs to consider increasing the ACP discussion with their patients. Primary care providers must create opportunities to meet the needs of their patients and their families. Established guidelines and reimbursement for ACP challenge PCPs to identify and contribute to the formulation of best practices to facilitate AD completion in primary care settings.

Improving Quality in the Care of Patients with Inflammatory Bowel Diseases.

Efforts to improve healthcare quality were firmly established before the Institute of Medicine (IOM) historic 2000 and 2001 reports, To Err is Human Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century Despite the long-standing healthcare quality improvement (QI) efforts that date back to the turn of the 20th century, the IOM reports significantly advanced the awareness of healthcare quality deficits and the resulting risk to patients from those gaps in care. Studies immediately following the IOM reports emphasized and verified the presence of detrimental care gaps and highlighted a myriad of contributing factors. Studies focused specifically on the inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis , demonstrated suboptimal patient outcomes stemming from, in part, system and provider variation. In the years that have followed, research studies have shown the persistence of suboptimal outcomes in IBD despite an awareness of key drivers for poor care quality and concerted efforts in advancing QI initiatives. In 2017, IBD advocacy groups and provider networks have demonstrated progress in furthering both pediatric and adult IBD outcomes through the use of QI methods and tools including collaborative learning networks. A significant amount of work lies ahead, however, to build upon these advances and improve IBD outcomes further. This article reviews the history of quality initiatives in healthcare, identifies ongoing gaps in IBD care with a review of current IBD improvement efforts taking place, and identifies several targets for improving IBD care quality moving forward into the 21st century.

Nursess Use and Understanding of the Letter 'A' in the S.A.F.E. Error Prevention Tool

In 1999 the Institute of Medicine (IOM) published its landmark report named “To Err is Human: Building a Safer Health Care System.” The report called for an extensive improvement in order to reduce medical errors which have resulted in permanent injury, even deaths. There are approximately 268 preventable deaths each day in hospitals across this country. On March 1, 2017, the Joint Commission issues a Sentinel Event Alert highlighting the industries and its leader’s failure to implement a culture of safety designed to reduces preventable error. Since the IOM report, some facilities have adopted Safety Science, High-Reliability, and behavior modifying error prevention tools to help change traditional practices. The problem: to date, there is no formal study or tool to measure nurses’ use and understanding of high-reliability Error Prevention Tools (EPT). The purpose of the quasi-experimental, quantitative, comparative study is to measure and compare (ED Nurses and ICU nurses) use and understanding of the S.A.F.E. EPT adopted by the clinical site three years prior to the study. The significance of the study is to inform the healthcare industry and the clinical site of nurses’ use and understanding of the EPT. The study was conducted using a 51 question M-HSOPSC. The nature, scope and limitations of the project focused on the letter “A” of the S.A.F.E. EPT. Of the respondents who participated in the study, the majority indicated they used and understood the (EPT). Using SPSS, Pearson correlation was used to determine directional relationship, Mann-Whitney was used as a non-parametric statistical analysis to compare ED & ICU nurses use of the Error Prevention Tool. Due to confounding variables, the sample effect size to detect a power of .80 was not met. The analysis did produce statistically significant results using a Sig .05.

Comparison of two breast cancer survivorship treatment summary and care plan (TSCP) documents.

49 Background: The 2005 Institute of Medicine report recommended providing a cancer TSCP, but barriers including time needed to complete these documents led to limited implementation. In 2014, in order to facilitate delivery, ASCO released a streamlined version of a TSCP. The current prospective, randomized study compares a Breast Cancer ASCO 2014 derived template (concise TSCP) with a facility derived Breast Cancer TSCP template based on the “old” ASCO version and NCCN guideline recommended elements (detailed TSCP). Methods: Female breast cancer survivors who completed therapy at Gundersen Health System were randomized between a concise TSCP and a detailed TSCP. Subjects received a survey prior to their survivorship visit assessing their baseline knowledge of their breast cancer diagnosis and treatment (pre visit knowledge). After the visit, participants completed the same survey (post visit knowledge) and a satisfaction survey. Pre and post visit knowledge survey scores, patient satisfaction scores and time needed to complete the TSCP were compared between the two study groups. Results: Both TSCP groups showed significant improvement in patient-specific disease and treatment knowledge scores (% of applicable knowledge questions answered correctly) after their survivorship visit. There was no significant difference between the concise and detailed groups’ pre-visit knowledge score (mean 78% vs. 79%, p=0.88). Calculated difference between the groups’ post knowledge scores met the pre-determined threshold for non-inferiority (p=0.013). Conclusions: Our study demonstrates the value of a cancer TSCP and Survivorship visit in improving breast cancer survivors’ knowledge of their disease characteristics and treatment. The concise version was found to be non-inferior to the detailed TSCP in terms of patient knowledge and satisfaction and required less time to complete. These results assist us and other institutions in choosing a more streamlined version of TSCP without compromising patient knowledge or satisfaction. [Table: see text]

A Guide for Palliative Medicine Clinicians Taking Care of Lesbian, Gay, Bisexual, and Transgender Patients Using a Whole Person Care Approach (SA516)

•Understand the impact of spiritual and existential distress in LGBT patients with chronic medical illnesses.•Access tools and resources to support LGBT patients and families facing life threatening illnesses and uncertain legal protection state-by-state.•Assess the unique needs of transgender patients who are receiving care from faith-based organizations. In 2011, the Institute of Medicine report on the Health of Lesbian, Gay, Bisexual, and Transgender (LGBT) People cited lack of legal protections and lack of social support as significant barriers to the quality of palliative care. LGBT patients have achieved expanded rights and access to health care. State health policy and legislation varies widely across the country and many states offer little legal protection to LGBT patients. LGBT patients living with chronic illnesses experience higher rates of depression and anxiety and more likely to have lower rates of satisfaction with care that they receive from health care providers (Kamen C 2015). Healthcare providers receive little training on caring for LGBT patients and often are unaware of educational and patient support resources for LGBT patients. While LGBT patients and their families are reported to have higher preferences for advance care planning, palliative care, and hospice many palliative care and hospice organizations lack policies and educational resources in regard to care of LGBT patients and families. Our transdisciplinary team of co-presenters includes representatives from medicine, advance practice nursing, social work and chaplaincy. The presenters will use case-based teaching to highlight the role of chaplaincy in assessing LGBT specific spiritual and existential distress. We will address the role of chaplaincy in promoting psychological well-being in LGBT patients by chaplain led Dignity Therapy. We will address the role of social workers to proactively promote formalized surrogate decision makers of LGBT patients’ preference, psychosocial well-being and resources to address variability in state protection for LGBT patients. We will address the role of hospice and palliative medicine teams in caring for transgender patients with advanced illnesses who are receiving care from faith-based and long-term care organizations. We will present resources for providers to educate their teams on caring and advocating for LGBT patients. •Resources to Improve The Quality Of Hospice And Palliative Care For Sexual And Gender Minority Patients And Families•Center of Excellence For Transgender Health - http://transhealth.ucsf.edu/•Hospice Foundation of America LGBT Resources- https://hospicefoundation.org/End-of-Life-Support-and-Resources/Coping-with-Terminal-Illness/How-to-Choose/LGBT-Resources•Lambda Legal Tools for Life and Financial Planning- http://www.lambdalegal.org/publications/take-the-power•LGBT best and promising practices for cancer care for LGBT patients and families throughout the cancer continuum- http://www.lgbthealthlink.org/Cancer-Best-Practices•LGBT Hospice and Palliative Care Network – https://lgbthpm.org/resources/•National Resources Center on LGBT Aging - http://LGBTagingcenter.org/resources•Services and Advocacy for Gay, Lesbian, Bisexual & Transgender Elders- http://sageusa.care/ Institute of Medicine: The Health of Lesbian, Gay, Bisexual, and Transgender People Building a Foundation for Better Understanding. Washington, DC: National Academy of Science, 2011. Kamen C, Mustian KM, Dozier A, Bowen DJ, Li Y. Disparities in psychological distress impacting lesbian, gay, bisexual and transgender cancer survivors. Psychooncology 2015 24(11):1384-91.

Editorial introductions

Editorial introductions

Medication Errors in Critical Care Units in a Tertiary Hospital

Medication errors in critical care are frequent, serious, and predictable. Critically ill patients are prescribed, twice as many medications, as patients outside of the intensive care unit (ICU) and nearly all of them suffer, a potentially life-threatening error at some point during their hospitalization. Today, in the health care profession, all types of medication errors including missed dose, wrong dosage forms, wrong time interval, wrong route, etc., are a big deal, for quality patient care. Problems related to medications, are common in the healthcare profession, and are responsible for significant morbidity, mortality, and cost. Several recent studies have demonstrated that patients frequently have difficulty in reading and understanding medication labels. According to the Institute of Medicine report, “Preventing Medication Errors”, cited poor labeling as a top most cause of medication errors in the USA. Evidence suggests that specific content and format of prescription drug labels, facilitate a better communication to minimize apprehension by patients regarding medication errors.

Results of implementing a novel supportive oncology screening tool for comprehensive evaluation of distress and other supportive care needs.

61 Background: The Institute of Medicine (IOM) 2013 Report recommends that supportive oncology care start at cancer diagnosis; the Commission on Cancer (CoC) Standard 3.2 requires distress screening and indicated action. Screening tools are not standardized and often address only a portion of patients’ supportive oncology needs. Methods: A collaborative of 100+ clinicians, funded by The Coleman Foundation, developed a patient-centric screening tool adapted from NCCN Distress Problem List, IOM report and CoC standards, with validated sub-tools: PHQ-4 for anxiety and depression and PROMIS short forms for pain, fatigue and physical function. Novel treatment/care and other concerns were included. The screening tool was implemented at 4 cancer centers (2 academic, 1 public & 1 safety-net). End points included correlation of PHQ-4 score with other supportive oncology needs. Descriptive statistics, Fisher’s exact test were used. Results: 2805 patients were screened. Average scores were: PHQ4 – Anxiety and Depression 1.8 (mild > 3), Pain 4.5 (mild > 4), Fatigue 8.8 (mild > 6), Physical Function 20.2 (mild < 20), see table for additional items. Higher scores on the PHQ-4 were significantly associated with each of the following: greater pain, fatigue, , nutritional and specific treatment/care concerns, and lower physical function (p<.0001). (See Table). Conclusions: Patients with higher anxiety and depression also have many other supportive oncology concerns. Our results support the use of a comprehensive tool capturing a spectrum of each patient’s unique concerns. This may enable earlier interventions and personalized delivery of supportive care. [Table: see text]

Quality, Reliability, Repeatability - What about Excellence?

ABSTRACT Today, I will be giving a general overview of the quality question. I will divide quality into four topics: first essential element—data, second essential element—process, third essential element—culture, and hidden dangers. We were fairly “high on the hog” in the House of Surgery in the late 20th century but then came the Institute of Medicine (IOM) reports. Partly in response to the IOM reports, we have discussed incessantly airplanes and aircrews. However, this is not the only challenge for in addition to this quality problem, we have a cost problem. These intersecting challenges appear insurmountable, but there is hope. We need better data, better process, and an evolution of our culture. The easiest type of data to collect is process measure data. We should all be aware of Surgical Care Improvement Project (SCIP), Physician Reporting Quality System (PRQS), and Merit-Based Incentive Payment System (MIPS). On the performance measures side of the house, the National Surgical Quality Incentive Program and the University Health-System Collaborative are major initiatives. There is an abundance of data, but if we are to improve care, we also need a good process. There is increased attention into process such as checklists, bundles, and standard operating procedures. Data and process is important, but we also need to be strategic. For a process to be effective, it needs to be part of a coherent strategy. And once we have data, process, and strategic thinking, we come to the third essential element, which is culture. Are there some dangers in embracing these new approaches? In a word, yes. We cannot abandon the traditional role of surgeons as leaders. We need to think about training the next generation of surgeons and the risk that this over-systemization of care begets. Surgeons have always led change, so though these new challenges seem profoundly disruptive, I am sure that we will again rise to the task.

Areas for quality improvement in pediatric supportive oncology services.

146 Background: In 2013, the Institute of Medicine report recommended that supportive oncology services be initiated at time of diagnosis. Providers of pediatric cancer care in the Chicagoland community, supported by The Coleman Foundation, sought to define areas for quality improvement of supportive oncology delivery to children. Methods: Focus groups and surveys with clinicians providing pediatric cancer care and supportive services at 14 sites were used to prioritize areas needing improvement. Results: 100% (14/14) of sites participated. Of the eligible sites, 6 were pediatric cancer treatment sites and 8 cancer care community organizations. Sites demonstrated consistent agreement for 8 of the 12 areas of focus for improvement. Over 50% of sites reported areas of focus (table) as important or very important. Conclusions: Sites identified the need for quality improvement in delivery of psychosocial, survivorship and palliative care for pediatric cancer patients. Survey results demonstrate a need for collaboration and efforts to guide care delivery improvement across sites. [Table: see text]

Implementing the Clinical Nurse Leader Role in a Large Hospital Network

In 2011, the Institute of Medicine (IOM) provided statistics regarding the future of health care based on legislative changes during 2010. According to the IOM's report, 1 an additional 32 million Americans would receive health care benefits by 2012. Additionally, it is estimated that by the year 2025, health care will face a shortage of more than 350,000 nurses. 2,3 The influx of new lives in America requiring medical care and the estimated lack of resources provide multiple challenges for hospitals, including organizing new models of care at the bedside to improve care coordination and to enhance interprofessional collaboration. 4,5

Are Today’s EHR Alerts Putting Clinicians, Patients at Risk?

Are Today’s EHR Alerts Putting Clinicians, Patients at Risk?